Whole Body Health Acupuncture Center

Heather Vandeburg L.Ac., MSOM

547 W State St Sycamore IL 60178

Ph (815) 751-6424     

Thank you for choosing our office!!  In order to serve you properly, we need the following information.   All information will be kept confidential.

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Patient Name:							Today’s Date:
Home address:					City:		State:	Zip:
Home phone:		Work Phone				Email address:
Birth date:	Social Security #:					Height :		Weight:
Circle appropriate:              Minor               Single               Married               Divorced               Separated               Widowed
Person to contact in case of emergency:			Their Relationship to you:			Their Phone Number:
Patient’s Occupation:				Who might we thank for referring you?

Insurance information:

Insurance company:		Referring Physician:
Patient’s (or parent/guardian’s) employer:
Business Address:	City:		State:	Zip:
Spouse (or parent/guardian’s) Name:		Spouse’s Occupation:
Spouse (or parent/guardian’s) Employer:		Spouse’s Work phone:
Office Notes:

HEALTH HISTORY QUESTIONNAIRE

Have You ever been treated with Acupuncture or Oriental Medicine before??     YES     NO

What Main Problem(s) would you like us to help you with?

What Other Medical treatment(s) or alternative therapies have you tried for this problem?

DO YOU CURRENTLY HAVE PROBLEMS WITH ANY OF THE FOLLOWING?

Allergies	High Blood Pressure	Recurrent Infections
Arthritis	High Cholesterol	Recurrent Sore Throats
Asthma	Kidney Disease	Sensitivities
Cancer	Kidney (or Bladder) Stones	Sinus Congestion
Chronic Infections	Liver Disease	Sprains or Bruising
Diabetes	Lung Disorder	Stomach Disorders
Eye Disease	Menopausal Symptoms	Substance abuse
Fatigue	Mental Illness	Tuberculosis Exposure
Food Cravings	Numbness or tingling	Tumor
Gall Bladder Disease	Obesity	Varicose Veins
Heart Disease	PMS	Wear Eyeglasses
Heart Burn	Poor Circulation	Other:
Headaches /  Migraines	Psoriasis, Eczema, Acne	Other:
Hemorrhoids	Recent Surgery	Other:

FAMILY HISTORY:

Relatives	If Living		If deceased
	Age	Health (good, fair, poor)	Death age	Death cause
Father
Mother
Brothers/Sisters (Circle sex)
1.      M        F
2.      M        F
3.      M        F
4.      M        F
5.      M        F
Spouse
Sons/ daughters (Circle sex)
1.      M        F
2.      M        F
3.      M        F
4.      M        F
5.      M        F
6.      M        F

Please list any blood relatives who have or have had any of the following conditions:

	Yes	No	Relationship		Yes	No	Relationship
Alcoholism				High Blood Pressure
Allergies				Kidney Disease
Anemia				Leukemia
Arthritis/ Rheumatism				Mental Illness
Asthma				Migraine/ Headache
Bleeding Tendency				Nervous Breakdown
Cancer				Obesity
Colitis				Rheumatic Fever
Congenital Heart				Stomach Ulcers
Diabetes				Stroke
Epilepsy				Suicide
Goiter				Tuberculosis
Heart Disease/ Stroke				Other:

Your Personal Habits:

Do you smoke?	YES         NO	If Yes, # of packages per day
Do you Drink Coffee?	YES         NO	If Yes, # of cups per day
Do you Drink alcohol?	YES         NO	If yes, # of drinks per day

If available, please bring your most recent lab/blood work results to your first session.

Document your Test Levels of the following, if known:

Blood Pressure Level:

Cholesterol level:

Check any you are you currently taking or have taken within the last 3 months:

Antacids	Cough Medicine	Steroids
Antibiotics	Herbs	Tranquilizers
Aspirin	Insulin / Diabetic pills	Thyroid medication
Blood Pressure Pills	Iron Pills	Vitamins
Blood Thinning Pills	Laxatives	Water Pills
Birth Control Pills	Sleeping Pills	Weight Reducing Pills

BRIEF HEALTH HISTORY

Operations you have had:	Include Years
Diseases you had requiring hospitalization:	Include Years
Serious Illnesses you had not requiring hospitalization:	Include Years
Describe any serious injuries or accidents you have had:	Include Years
Have you ever worn a neck or back brace?	YES        NO
List any known Drug Allergies you have:

PLEASE LIST YOUR MEDICATIONS:

NAME	DOSAGE	INDICATION	LENGTH OF TREATMENT
1.
2.
3.
4.
5.
6.
7.
8.

PLEASE LIST YOUR SUPPLEMENTS OR OVER THE COUNTER MEDICATIONS:

NAME	DOSAGE	INDICATION	LENGTH OF TREATMENT
1.
2.
3.
4.
5.
6.
7.

HEART

	Normal Blood Pressure	Low Blood  Pressure	High Cholesterol	Palpitations
	High Blood Pressure	Dizziness upon standing	Congenital Disease
Explain:
Professional Notes:

HEADACHES

Do you frequently have Headaches?     YES   NO   (If yes, answer the following):

	Cause visual trouble?	Do they occur on the side?	What is the duration?
	Awaken you at night?	On the back?	Does aspirin relieve them
	Pain is  sharp and stabbing	In the front?	Do they involve dizziness or weakness
	Pain is  dull and achy	At the eyes?
	Pain feels  like a tight band?	On top?	Are they aggravated by Overwork?
	Head feels heavy?	Sinus area?
Other Description:
Professional Notes

PAIN:

Location		Constant       or         Intermittent
Time of day it’s worse	Better or worse with cold?	Better or worse with heat?
Better or worse with pressure?	Pain intensity 0-10	Does pain move?
Better or worse with activity?	Is there a heavy feeling?	Is the pain sharp and stabbing?
Is the pain dull and achy?	What is its duration?
Explain:
Professional Notes:

If you have stomach pain, does the pain…

	Occur within 1-2 hours after eating	Occur after eating fried foods?	Awaken you at night?
	Go away with an antacid?	Go away after a bowel movement?	Cause a loss of appetite?
Explain:
Professional Notes:

THIRST

	Thirsty	No thirst, but drinks lots anyway	Prefer cold drinks
	Absence of Thirst	Dry Mouth	Prefer room temperature drinks
	Thirst with little desire to drink		Prefer hot drinks
What do you drink throughout the day?			Quantities:
1.
2.
3.
4.
5.
6.
7.
8.
Professional Notes:

APPETITE and DIGESTION (Check those that apply)

	Rapid hungering	Indigestion			Loss of taste
	Poor appetite	Acid Reflux			Canker sores
	Hungry,  but no desire to eat	Preference for salty food			Toothaches
	Not hungry, but desire to eat	Preference for fatty foods			Halitosis
	Nausea	Preference for sweets			Diverticulitis
	Vomiting	Bitter taste in mouth			Undigested food in stool
	Bloating	Sweet taste in Mouth			Eating Disorder
	Gas/ flatulence	Sour taste in mouth			Other:
Do you consider your weight to be:   Normal, Overweight, or Underweight?				How many pounds would you like to gain or lose?
What is a typical Breakfast for you?			What is a typical Lunch for you?
What is a typical Dinner for you?			What are typical snacks you eat?
What foods do you crave?			What foods do you avoid?
Explanations:
Professional Notes:

URINATION

	Frequent	Burning	Cloudy	Foul Smell	Difficult start	Large amount
	Urgent	Painful	Dark Color	Bloody	Incontinence	Small amount
	Kidney stones	History of bladder or kidney infection		Other:
# of times / day				# of times / night
Explain:
Professional Notes:

BOWEL MOVEMENT:

	Constipation	Watery		Thin	With Mucous	Black
	Diarrhea	Incomplete		Formed	With Blood	Yellow
	Loose	Hard & Dry		Strong Smell	Light to dark brown	Green
# of bowel movements per day:			Explain:
Professional Notes:

UPPER RESPIRATORY:

	Chronic Cough	Thick sputum	Sore throat	Sinus infection	Sinus headache
	Bronchitis	Green sputum	Post nasal drip	Swollen sinus	Wheezing
	Profuse, watery sputum	Yellow sputum	Dry sinus	Congestion	Snoring
Explain:
Have you ever been allergy tested?                   YES         NO
If yes, what substances did you test positive for?
Professional Notes:

VISION

	Loss of vision	Eye pain	Eyelid drooping	Macular Degeneration	Burning eyes
	Dry eyes	Red eyes	Glaucoma	Flashes / Floaters	Discharge from eyes
	Excessive tears	swollen	Cataracts	Double vision	Itchy eyes
Explain:
Professional Notes:

HEARING:

	Hearing Loss	High Pitched Tinnitus	Clogged Ears	Vertigo
	Ear Pain	Low Pitched Tinnitus	Drainage	Other:
Explain:
Professional Notes:

SKIN

	Rashes	Psoriasis	Skin ulcers	Bronchitis
	Eczema	Acne	itching	Pneumonia
	Rosacea	Prickly heat	Dry skin	Oily skin
If so, where?
Professional Notes:

PERSPIRATION (check those that apply)

	Too easily	Frequent sweating	Feet Sweating
	Too little	Night Sweats	Absence of Sweating
	Profuse sweating	Palms Sweating	Other
Describe:
Professional Notes:

TEMPERATURE (Check those that apply):

	Feel cold easily	Alternating hot and cold	Cold weather bothers you
	Feel hot easily	Experience hot flashes	Hot weather bothers you
	Cold Hands	Sensitive to weather changes	Damp weather bothers you
	Cold feet	Sensitive to barometric change	Windy weather bothers you
Describe:
Professional Notes:

SLEEP:

	Wake refreshed	Awakened by pain		palpitations
	Difficulty falling asleep	Sudden awakening		Night sweats
	Difficulty in falling back asleep	Nightmares		Can’t stop thinking
	Awakened easily	Susceptibility to fear & fright		Restlessness
	Difficulty waking	Anxiety		Drowsiness during the day
	Early morning waking	Irritability	# of hours of sleep/night
	Dream Disturbed sleep	Worry
	Unwanted movements	Poor memory
Explain:
Professional Notes:

REPRODUCTIVE (Women only)

Age of first Menses:

Are you still having regular monthly menstrual periods?

If no, when & why did it stop?

Are you now or have you ever  taken the birth control pill?

If so, when?

Have you ever                had a miscarriage?

If yes, how many Miscarriages, and when?

Do you regularly have the cancer test of the cervix?

Date of last test:

How many children born alive?

How many cesarean operations?

Explain any complications of pregnancy:

Do you have recurring yeast infections?

How many days per cycle?

How many days does it last?

Is your cycle regular?

Is color of flow…

Pale red?

Dark red?

Bright red?

Purplish?

Do you ever have clots?

If yes, are color of clots…

Pale red?

Dark red?

Bright red?

Purplish?

Is amount of flow…

Very light?

Light?

Normal?

Heavy?

Very heavy?

Is Quality of flow…

Thin?

Normal?

Thick?

Do you have bleeding between your periods?

If yes, how often and amount:

Do you have any type of pain?

Before flow?

During flow?

After flow?

Is the pain located in the …

Head?

Chest?

Abdomen?

Side of chest?

Breasts?

Lower back?

Is the pain relieved by…

Heat?

Cold?

Pressure?

Is the pain aggravated by…

Heat?

Cold?

Pressure?

Is the pain…

Dull?

Sharp and stabbing?

A burning sensation?

A “bearing down” sensation?

Emotions around period…

Depression?

Irritability?

Anger?

Sadness?

Crying?

Do these emotions come…

Before flow?

During flow?

After flow?

Professional Notes

REPRODUCTIVE (Men only)                

Have you ever had Loss of sexual function?		If yes, for how long?
Treatment for genitals?	Hernia (rupture)?		Prostate Disease?
Professional Notes:

ENERGY

	Low	Exhausted	Nervous energy	Changes in memory
	Up & Down	Hyperactive	Abundant	Normal
Libido:                      Low? Average? High?
Explain
Professional Notes:

EMOTIONS

	Depression	Panic Attacks	Worry	Angry	Irritability
	Sadness	Sensitive	Overly Excited	Anxiety	Memory Problems
Explain:
Professional Notes:

Do you frequently have any of the following:

	Bleeding gums	Hoarseness	Spells of Dizziness	Weakness of arms or legs
	Halitosis (bad breath)	A sore tongue	Fainting Spells	Hair loss
	Trouble swallowing	Nosebleeds	Edema/ swelling	Convulsions
	Mouth Sores
Explain:
Professional Notes: